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Thank you. Yes. Uh, sorry. Can everyone hear me? Okay. Yeah. Yeah. Great. OK, super. So good morning, everyone. I hope everyone's nice and safe. I understand there's been some communication breakdown in Ukraine because of the troubles. I'm very sorry to hear that. Um, recorded. And so I hope people have an opportunity to see this a bit later on. What I've done is I've posted in the chat the link to the Paxman cases that I'm about to show you, and we're going to start with number 20. So if you'd like to open number 20 and I want you to look at the the pa and the electrical chest X ray, can everyone see that? Okay. And I'd like you to tell me what you think is going on. Just put it into the chat. What you think might be going on. Any thoughts? I wonder whether the moderator would be kind enough, uh, to repost that packs been link. Uh, as as we get more people coming on to the zoo, if that's okay, I'm not able to For some reason, I'll try and connect with a different device because I'm not able to copy and paste the link. Or maybe you can WhatsApp it to me. If that's not too different, I'll just keep. I'll just keep on doing it. That's fine. So no, that's absolutely fine. No problem at all. So for those of you who have just joined, I've put in a packs been link, which opens a whole series of cases which you are able to scroll through yourself. And this patient has got a P a chest X ray. I know it's a pa, a chest X ray, because the scapula have been projected away from the thorax and the heart sizes normal. But I can't see the right heart border now anatomically, which lung segment or lobe is sitting next to the right heart border? Yeah, middle lobe perfect. And it's very nicely demonstrated on the lateral view because we can see that the horizontal fissure and the oblique fisher have come together and the lobe has become solid, and the lobe has become solid because all the gas has been expelled from this lobe because of low bar collapse. Now, because the right middle lobe sits adjacent to the right heart border, you are then unable to see the right heart border on the PA film. And that's simply because the radiographic density of the right heart border or the heart is exactly the same as the radiographic density of the collapsed lobe. And therefore you lose the ability to see the right heart border. And this is a middle lobe collapse. Okay, now, ordinarily, when you get a low bar collapse in an adult patient, it almost always means that you've got an endobronchial tumor search as a bronchial carcinoma. But in the case of a middle lobe, it's probably not a bronchial cast namer. It's more likely to be mucus plugging, so asthma Asthmatic patient's patient's who've got a history of mucus plugging, uh, will tend to develop mucus plugs. And because it's a very small bronchus, it's more susceptible to undergoing, um, collapse, as you can see in this particular case. Okay, so I'm going to come out of this one, and I'm going to go to number 21 and I want you to tell me what's going on in this patient patient with abdominal pain. So it's an inspiratory film. It's a pa film because the scapula have been projected away from the thoracic cage? Yeah, the heart sizes normal. Yeah, there's gas under the diaphragm. So if I, um, just show you this one So this is the same patient. It's just an X spirito review. And can you see both sides of the diaphragm? You can see the upper part of the diaphragm and the lower part of the diaphragm, and it's maybe a millimeter or two millimeters in thickness. And this is due to a pneumoperitoneum due to perforation? No. The important thing here is that we can see both sides of the diaphragm. Ordinarily, you would only see one side of the diaphragm. Okay, so in a normal chest X ray, you would see one side of the diaphragm, so I'm going to try and show you what I mean. Um, just gets a normal chest X ray. Okay, So if we go to this particular image here, can you see that the lung is interfacing with the diaphragm and all you can see is lung interface and then soft tissue. That soft tissue is the combination of the diaphragm and the liver because the diaphragm has the same radiographic density as the liver. Okay, but what we've got here is We've got the diaphragm are putting the lung and the lung. Uh, sorry. The under surface of the diaphragm is a boating rated abdomen. So there must be pneumoperitoneum because you can see both sides of the diaphragm. And this means that the patient is almost certainly perforated. Now, if you want to work out whether somebody's had a perforation or not by using an X ray Uh, an erect chest X ray is much more sensitive than an abdominal film and an abdominal film to look for perforation is a bit turkey, and I'm going to discuss that in future lectures. Okay, but this is a nice example of a perforation. So what's what's the commonest cause of a perforation in your practice? Anyone Name? Put it into the chart. Perforation of what? Yeah, Jude In also. Absolutely right. Absolutely Right. Okay. So the next one I'm going to show you is number 22 which is this one here. And I want you to tell me what's going on on this particular chest X ray. So the patient has had a pneumothorax. They've had a chest drain inserted, but the chest drain doesn't seem to be working because when you put a chest drain in and connect it to an underwater seal, the water level in the underwater seal tends to swing up and down. But it's not happening in this case. And can anyone to tell me why? Where is that intercostal tube? Yeah, so during the pneumothorax, the left lung has collapsed. But why has the intercostal tube failed to re inflate the lung? Any thoughts? Because it's perfect to the PLO ra. So what happens is when you have a pneumothorax, it's almost always due to a breach of the visceral pleura that lines the lung. So whatever is going on in the lung, whether it be emphysema or positive pressure, ventilation, uh, or even a stabbing. It's the gas that comes out of the visceral pleura into the pleural space that produces the pneumothorax. Now you can also get gas coming in from the outside through the parietal pleura to give you a pneumothorax, but it's usually the other way around. Now, when you put the chest drain in, the lung is already collapsing because of the increased pressure in the pleural space. But in this particular case, there's the tip of the tube. So where do you think the side whole of the tube might be? Do you think it's here? Oh, here she gets at the first point, just there or the second point. What do you think? Yeah, it's the second point, isn't it? So what's happening is the gas is coming out of the pleural space through the tip of the tube. And instead of going straight into the underwater steel because the side hole is outside the pleura, it's producing all of the surgical embassy. And so what's the solution to this particular problem? And you may encounter this in your in your practice as, uh, foundation doctors. What would be your solution? Reinsert. Yeah, Or what can you do? Which is simpler? You could just push it forwards, advance it about 34 centimeters that would that would work very nicely if you were concerned about damaging the lung. You shouldn't be because there's quite a big space between the tip of the tube and the lung. But you can always ask the radiologist to assist you in this. If you thought that you were going to damage the link, so the reason why we've got so much surgical emphysema in this particular case is because the side hole is outside the chest wall and therefore all the gas is coming out that side hole and into the subcutaneous tissue before it gets into the underwater seal. Is everyone clear on that? Okay, so the next one is 23 and 23 is, um, just get these in chronological order. We've got another patient, and this may be a repeat, but I just want you to understand, uh, this, uh, concept pretty well, patient's got abdominal pain and it's severe. And when the surgeon puts the hand on the patient's to me and presses down, they get rebound tenderness, and there's Paris in is, um So what you do with the diagnosis is you may personally, um, again, yeah, you can see both sides of the diaphragm. You see both sides of the diaphragm, and there's a huge amount of gas under the diaphragm, and it's due to perforation and most likely due to perforated Judean. Also. Now this is exactly the same patient, and there's an abdominal film, and it was taken about the same time as the chest X ray. Now I think it's really, really difficult to see gas in the abdomen on this film, Okay, it's much easier to see the gas under the diaphragm seems because it's an AP erect film, so gas is going to rise and it's gonna going to go into the diaphragm. But when you're doing an abdominal film, the patient's in a supine position and you don't get gas rising to go underneath the diaphragm. And in fact, in most abdominal films, you never see the diaphragm. Okay, but the very subtle sign of Pneumoperitoneum on this case is this almost like a triangle of gas and that triangle of gasses in Morrison's pouch. Does anyone know where Morrison's perches? No. Okay, so Morrison's pouch is in the peritoneal space, and it's just in front of the kidney and just behind the liver. So it's the Hepatorenal recess, okay? And it's called Morrison's pouch and in the lying down position, gas that's free to roam and the abdomen will get trapped in this particular space. Okay, so this is, uh, Pneumoperitoneum, And the other feature, which is a bit more subtle, is you can see both sides of the bowel wall just here, and that's because we've got pneumoperitoneum. But I'm sure you'll all agree that the easiest way of picking up pneumoperitoneum is to see gas under the diaphragm. And so doing an erect chest X ray in patient's who you suspect of having, um, new person. A medium is the right thing to do. Any questions on that? Okay, 24. Okay, let's have a look at the history in this patient. No history. Okay? I'll make up a history then. So this patient is a smoker, and they've got a cough and weight loss. Any thoughts before you look at the chest X ray? What would be your clinical suspicion? Got what response? Oncology. So yes. Yeah, that's absolutely right. So you're thinking about a malignancy? And the malignancy is somebody who smokes and who gets weight loss. Uh, certainly in the UK, we think about the bronchial carcinoma. Now, bronchial carcinoma can present in several ways. It can present as a mass or a nodule on the chest X ray. Does anyone know what the difference between a mass and the nodule is? We talked about nodules, and we can talk about mass allusions. Any, um, any thoughts about why we call them one or the other? Well, a nodule is less than three centimeters, whereas a mass lesion is greater than or equal to three centimeters. Okay, simple as that. Really? Now you can already see that there's no mass lesion or nodule here. But can you all see that this lung is hyper trans radiant with respect to that one? So, in other words, this is more dense than the left lung or putting it another way, the left lung is less dense than the right lung. The other thing is, there's a bit of volume loss here in that left Hemi thorax. And can you see a sale shape behind the house? So which lobe collapses by going towards the midline and towards the back of the thorax? Any thoughts? Yeah, low. Yeah. So it's the left lower lobe collapse. And what happens with the left lower leg collapse is that the left lower lobe collapses towards the midline and towards the posterior thorax. And so, uh, this is nicely shown on the CT scan, which I will display over here. So as I scroll through the thorax, I hope you're all able to scroll through the image which is yourself. Can you see that there is a collapsed left lower lobe and it's collapsed. Why is it got a higher attenuation than the surrounding lunk? So I'm just gonna put this on linguine does. Why does the collapse lobe have a higher attenuation, or was it denser than the adjacent lunk? Anyone new? Not calcification? No, not cancer cells. So the reason why the lung looks like this is because it's got gas in it. Okay, But if you've collapsed your lung, you're not going to get any gas into it. And so a collapsed lobe was going to look more solid, and this is no exception, because this patient has got collapse of the left lower lobe. Now, the blood vessels are still patent in that left lower lobe. So blood vessels, when they have a contrast in them, make whatever structure that they run in look dense. And so this is no exception. This patient has got a left lower lobe collapse. Okay. And in this particular case, the left lower lobe collapse is caused by an endobronchial tumor. Now you may, or you may not see it on the CT scan, but these patient's always need a bronchoscopy to work out what's causing the global collapse, and it's usually an endobronchial tumor. Now the other thing that the CT can do is it can stage the cancer. Okay, so we can see whether or not there are any enlarged lymph nodes in the mediastinum. And looking below the diaphragm, we can see whether or not um, there are any metastases in the liver. There are not. There's just a very large cyst in the liver. Just, uh, there's the stomach. There's the spleen, There's the left kidney, there's the pancreas, and I always look very carefully at the adrenal plans, and it looks like a wishbone or a V shape. And the reason I look very carefully, the adrenals is that it's a very common site for a lung cancer to metastasize to. Okay, so this is a very nice example of a left lower lobe collapsed. And if I was to show you what it looks like on the lateral film, I don't have the lateral film for this patient. But I do have a sagittal CT, and you can imagine that this collapsed lobe is going to cause an increased density at the back on the lateral film, okay? And that's because it's collapsing towards the midline. Okay, towards the midline and towards the back. So this is a left left lower lobe collapse. And in my practice, the most common cause of a low bar collapse, as I said before, is an endobronchial tumour. So it's linked cancer. Okay, Now, um, I'll show you the last one. Now, this is a young patient who is complaining of recurrent chest infections and cough. Any thoughts? Does anyone know what this thing is? Here? What do we call us? It's called a port. A cath. Okay. And a Porto calf is a device that you can inject into to put in antibiotics and the antibiotics go in to the central veins and have a maximum effect on the lungs and the rest of the body. Okay, so a portacath is a long term catheter inserted in these patient's in order to inject, um, antibiotics or, uh, in some cases, chemotherapy. But this is, um, for antibiotics. Now, this patient has got lots and lots of thickened bronchi. Some of the bronch I've got gassed in and some have gotten puss in. So it's a young patient. You can see they've also got middle lobe collapse or consolidation because I can't see the right hot border. It's probably consolidation, given the fact that everything else looks like it's thickened. Bronch I with pussy. But it could also be collapse. And the only way of really finding out whether it's collapse or consolidation of the middle Labor's to do a lateral. Um, Now this problem is predominantly affecting the mid and upper zones more than the lower zones. Does anyone know what the diagnosis might be? Not COPD. It's a very young patient they've never smoked. Um, there it is, certainly pneumonia. Uh, it's tutus is stick fibrosis. Cystic fibrosis gives you bronchiectasis ISS and the bronchitis, uh, just produces lots and lots of sputum and lots of lots of sputum is characteristic of cystic fibrosis, and they frequently get repeated infections, which is exactly what this patient gets. And that's why they have the portacath inserted. Okay, so I think that's the end of those, uh, examples impacts been. I'm going to go on for about another five minutes just by showing you some trauma cases, and the next time we meet, I'm going to set up some more, uh, pack spin cases, this time on the brain. So we're going to go through brain imaging, which is obviously a very important part of medicine these days. But I just wanted to show you a bit of trauma. Now, there's such a thing called a flail segment. Does anyone know what a flail segment is? Any thoughts when you breathe in, the chest expands and the diaphragm gets depressed. Okay, When you breathe out, the diaphragm comes up and the chest rule contracts. Okay, so when you've got a flail segment, it means that you've got a fracture in two places in two consecutive ribs. So this rib here has got a fracture there, and the fracture of the this rib here has at least one fracture there, Possibly a fracture there. Can't see us. There's a fracture there, fracture there. Probably a fracture there as well. So if you've got two consecutive ribs which have more than two fractures, that's going to produce a flail segment. So when the patient breathes in this past, the chest will cave in and it's a surgical emergency because the patient may well have a pneumothorax, which they have here, but the lung will never expand even if you put a chest drain in because the chest wall is not supporting the muscles of respiration. Okay, so that's the flail chest. And that represents a surgical emergency. Now in the United Kingdom, what happens is we have surgeons who, um, who put, uh, screws and internal fixation into those ribs to get, um, the the the shape. And, um, the, uh, integrity of the thoracic cage is restored so that the patient can breathe and ventilate normally. And hyperventilation in these situations just leads to pneumonia. Okay, so this is called a flare or so I want to show you a tension pneumothorax, uh, seen in a patient who was involved in a road traffic accident. And you can see that there is a depression of the diaphragm. You have to take my word for it. Unfortunately, these e c g leads are just in exactly the same position as the diaphragm. This is the stomach, okay? And this lucency here is actually a pneumothorax. So that's gas in the pleur space. And can you all see the mediastinal shift? So I'm just gonna start. That's going far too quickly. I want to show you we're going from anterior to posterior. There's the sternum, and as we scroll through this trauma case, there's a really large pneumothorax. There's the diaphragm, which, you can see was obscured by the leads on the scout film. And here's the stomach. Okay, let's go a bit further. So there's lots of pneumothorax, which is in the anterior portion of the chest, because the patient is lying supine. Now the depression of the diaphragm tells me that this is a tension pneumothorax. So in other words, the intra thoracic pressure is much greater than the interrupt doing more pressure. And if that's the case, you're then gonna get flipping of the diaphragm because the tension inside the pleural space is so, so high now, can anyone tell me what causes death in attention? Hemothorax. All of this is confusion and hemorrhage, Constitution, confusion, confusion. There's the pneumothorax, so there's the spine, so we're posterior now in the chest. But as we can more anteriorly, just look at the diaphragm as we bring the scan more interiorly. See how it flips over. It's now concave upwards because of this massively increased pressure. So what kills patient's with this condition. Uh, collapse of lung? No. Okay, so we rely on the negative intrathoracic pressure for venous drainage into the right side of the heart. Okay, So the muscle pump of the calf muscle, together with the venous venous valves, uh, allows blood to move up from the toe or the feet in towards the, um, the right atrium. But we also rely on the negative intrathoracic pressure, which is, uh, generated during the respiratory cycle and that, if you like six venous blood into, um, the right atrium. But if you've got massive intrathoracic pressure rise as you do with attention pneumothorax, you're going to lose that ability to have the negative intrathoracic effect of, uh, allowing blood to drift into the right atrium. And if you've got no blood going into the right atrium, what happens to the circulation of the heart? So if you've got no blood going into the heart, what happens to the circulation within the heart? Yet you get a cardiac arrest, and so the cardiac arrest is as a direct result of too much pressure in the thorax. Okay. And the too much pressure thorax is obviously caused by a pneumothorax, and what usually happens is gets in either through the parietal Plourde a into the pleural space or through the visceral pleura into the pleural space. And whichever way it's coming into that pleural space, it's going in one direction. Okay, so there's probably a valve, so that gets in. But it can't get out, and the pressure eventually builds up, causing attention. Pneumothorax, which depress is the diaphragm and causes, Um, basically a cardiac tamponade effect. So you get no venous blood coming in, and then you get a cardiac arrest. Now, here's the most important question for today. What is the treatment for anyone in whom you suspect? Attention, pneumothorax. Any thoughts make it non tension. Brilliant answer. Brilliant answer. How are we going to do that? Yeah, just put a small caliber needle in the second intercostal space midclavicular line. Okay, now putting a chest rain in is correct, but it's not the first thing I would do simply because to put a chest drain in takes a bit of time. But if you put a needle in, that's relatively straightforward and easy to do, and it's a life saving procedure, and what would you here If you, um, put a needle in, you hear a whooshing noise like this push, and it lasts about 5 to 10 seconds. And when you hear that push, you know that the needle has gone in the right place and that you're dealing with a tension pneumothorax. And it's a life saving procedure because it then produces enough reduction in pressure to stop Any cardiovascular collapsed, and then it gives you plenty of time to put chest strain in at your leisure. Okay, so I've finished for today. I'm very happy to take any questions, too. All the next time. I'm hoping that, uh, the internet facilities in your country are going to be much better. Uh, and, uh, I hope everyone keeps safe. So thanks very much for your attention. Please do post some questions in the chat and, um, keep safe, and I'll see you next time. Thank you very much. My pleasure. My pleasure. Thank you very much, Doctor Curtis, I hope you can hear me. Thank you. Everyone who's joined. We really need your feedback forms completed. And before the end of this lecture, I will post the certificate once we have some feedback forms in. So please click on the link. Um and, uh, and submit your your feedback because we really need it to continue this initiative. Thank you very much. And I've also asked in the chat, if you can add anything extra you'd like to cover in these lectures. Excellent, Lecter. Thank you, Doctor. Curtis. My pleasure. Have a good day, everyone.